Female intimate surgery

Female Intimate Rejuvenation
Female intimate surgery

Dr Evgenii Leshunov reviews the present literary data on the history, methods and trends in female intimate surgery

Procedures aimed at correcting appearance and restoring functions that are carried out in the female urogenital area are customarily referred to as intimate plastic surgery (IPS). This surgery includes traditional methods of correcting vaginal prolapse and looseness of the vaginal vestibule, and also aesthetic correction of the vulva. The boundary between medical and aesthetic indications for the performance of procedures is blurred, and nowadays many operations are carried out with both objectives in mind.

A major contribution to the development of this sphere in the world is provided by cooperation between gynaecologists, urogynaecologists and reconstructive surgeons. Unfortunately in Russia we see a lack of mutual understanding between specialists engaging in “sexual medicine”, so that it is not possible to talk of the quality of the results of intimate plastic surgery or of sexual wellbeing as a whole. At the first interview with a prospective patient, a gynaecologist or surgeon should be able to provide a patient who is looking to have intimate plastic surgery with a full and informed explanation concerning all the options and the potential for correction in the urogenital area. The patient should, in addition, be examined by a psychologist to check for dysmorphophobia. It is important to be sure that the woman is taking the decision independently, without any coercion or pressure from her sexual partner.

Historical information
The previous history of female intimate surgery is associated with genital surgery—ritual manipulations that date back deep into antiquity and have distinct ethnic characteristics. Some approaches and methods used in modern-day sexual surgery have however been assimilated specifically from these rituals. One particular aspect of this surgery is that operative intervention is, in a number of cases, carried out not because of medical indications, but in connection with the patient’s dissatisfaction with her sex life.

Female genital mutilation is an operation that consists in the removal or resectioning of parts of the female genitalia, up to and including removal of the tip and part of the body of the clitoris (clitoridectomy) and the labia minora, performed without medical indications. As things stood in 2008, between 100 and 140 million women had undergone this operation, mainly in Africa (in Egypt, Sudan and Ethiopia, more than 80% of women have this operation), and also in Saudi Arabia and Indonesia. With time, it was female ritual circumcision that served as a prototype for female intimate cosmetic surgery.

To begin with, female intimate cosmetic operations were common among commercial sex workers, nude models, bathing suit models, actresses who appeared naked and certain categories of women suffering from such diseases as urinary incontinence, congenital sex organ development defects or birth-related injuries.

Articles about female intimate plastic surgery first began to appear in North American journals in 1978, and the first article describing a method of correction of the female urogenital area appeared in 1984. When Gary Alter presented the results of his own labiaplasty, vaginoplasty and G-spot enlargement work in 1998, there was a change in world opinion concerning intimate surgery. Although operations to tighten the vagina had been carried out earlier, the difference in the new methods was that they incorporated aspects of plastic surgery, and concentrated on the appearance of the vulva.

Intimate filling as a method appeared at the end of the 1990s, and did not begin to be actively used until after 2000. When the method first began to be practised, various fillers were widely used to augment the tissues of the anogenital area, and on occasion some of these did not meet safety requirements. In the USA, for example, numerous complications were seen that were linked to the use of implants based on bovine collagen and liquid silicone. For a long time a leading role in intimate plastic surgery was taken by lipofilling, often in combination with liposuction of the pubic region and the inside surfaces of the thighs. The first experience of lipofilling of the anogenital area was described by E  Hernandez-Prez in 1996. Following the commencement of use by cosmetologists of hyaluronic acid based products, doctors performing intimate zone correction also began to take a closer look at these. The first publications concerning the safe and effective use of products containing hyaluronic acid in sexual surgery appeared in 2003.

In 2006, the Italian plastic surgeon A. Alessandrini was the first to familiarise a Russian audience, at a congress in Moscow, with intimate filling methods. Since 2006, Professor Ya.A.Yutskovskaia and her colleagues have been engaged in the development and introduction of intimate filling methods for correction work in the anogenital area.

In discussing sexual medicine generally, mention must be made of the role played by professional medical societies. The International Society of Cosmetogynecology (ISCG) is the first, and the world’s largest, association of specialists in aesthetic gynaecology and intimate surgery. It was founded in 2004 by Marco A. Pelosi II and Marco A. Pelosi III, and takes in over 700 members and more than 30 countries. The society was set up with the aim of consolidating academic knowledge in the sphere of female intimate aesthetics and of making changes to gynaecological practice. Moreover the organisers appreciated that doctors working on sex-related problems enter into unique relations with patients, which provides an opportunity for fuller aesthetic control.

It is important to make the point that as medical activities become increasingly commercialised, the market for services on offer in the sphere of sexual medicine will grow, while the lack of a legal field in this area enables these services to be licensed in the certification register for a variety of types of medical activity. So perhaps specialists engaged in sexual medicine, be they urologists, gynaecologists or cosmetologists, will not run up against ethical/legal problems, but by the same token patients can anticipate strictly medical problems of quality control for the provision of medical services.

Intimate surgery—women’s views
Women go to a doctor both for aesthetic correction and because of functional disorders, including pain during the sex act or while engaging in sport, frequent irritation, vulvalintertrigo and discomfort while wearing underwear or clothing.

Women aged 18-44 prefer to undergo epilation in the bikini zone, which makes for better visualisation of the vulva. In 2008, D. Herbenick and colleagues carried out a study in which 2 500 women took part. The extent of the practice of pubic hair removal was investigated, and the ways in which it was done, and the influence of pubic pilosis on the quality of one’s sex life. The study results gave rise to the conclusion that a complete absence of pubic hair is linked to a higher FSFI (sexual function index) level.

Konig and colleagues discovered that 78% of 482 women questioned had learned about labiaplasty through the media, while 14% thought that their own labia minora looked abnormal. A feeling of awkwardness, “changing-room syndrome” and problems with sex life are also commonly adduced as reasons for wanting intimate correction. Bearing in mind the possibility of congenital deformations of the vulva, psychological problems may occur during the early adolescent period.

Possible dysmorphophobia should be borne in mind: one way or another it is the media who are to blame for this, by giving coverage to it in women’s magazines, alongside fashion and the accessibility of pornography on the Internet. Meanwhile the rise in the popularity of the procedures has spawned TV reality shows, where the subject of the ideal appearance of female external sex organs has been actively pursued. Michala and colleagues described a study of 16 girls (average age 14.5) who went to a clinic to have their labia minora (LMin) reduced in size. Six girls were worried about LMin asymmetry, while 10 complained of protrusion of the labia minora, regardless of their normal size.

The concept of ideal external sex organs among women in Western countries differs from that among women in other countries. In Rwanda and Mozambique, for example, extended labia minora are considered attractive, whereas in Japan the most attractive vulva is considered to be one shaped like a butterfly.

Doctors’ views
Traditionally, it has been gynaecologists who engaged in surgical correction of the vagina and vulva. Since growing numbers of urologists and plastic surgeons are carrying out labiaplasty, intimate filling and cosmetic vaginal operations, the need for correction of complications following interventions is steadily increasing. Most surgeons perform intimate plastic surgery without having had any training in aesthetic vaginal surgery. This gives rise to complications such as non-aesthetic appearance, functional incompetence of the vulva and sexual dissatisfaction. Increasing numbers of patients come to us for correction of such complications as asymmetry, excessive tissue removal, loss of sensitivity and pain in the vulvar area. Around 10% of interventions in the urogenital area that are performed at our centre arise out of unsuccessful operations.

In general, cosmetic surgery on the vulva does not require medical indications. According to the results of the consensus adopted in 2007 by the American College of Obstetricians and Gynecologists, the medical indications for intimate surgery are:

• the need to reconstruct the vulva following circumcision;

• asymmetry and hypertrophy of the labia minora;

• sclero-atrophic processes in the vulva;

• hypertrophy of the clitoris as a result of an excess of androgens.

Most surgeons, however, perform intimate plastic surgery with aesthetic objectives or to improve the quality of sex life of the woman and her partner. In a multi-centre, retrospective study, 76% of 258 women had an operation for functional reasons; 53% underwent an operation for cosmetic reasons and 33% to improve self-esteem. Fifty four percent of women who underwent vaginoplasty/perineoplasty and 24% of those who had the combined procedure, including vagino-/perineoplasty, labiaplasty and plastic surgery on the hood of the clitoris, did this to increase their partner’s sexual satisfaction.

Vaginoplasty is an intravaginal operation. Vaginoplasty is not intended to eliminate defects in the pelvic floor, but this reconstructive procedure is a modification of traditional colporrhaphy and is often carried out in conjunction with reconstruction of a pelvic floor prolapse.

Classically, the vaginoplasty procedure involves anterior or super-posterior colporrhaphy, modified by the use of plastic surgery methods, excision of the lateral wall of the vaginal mucosa, and also a combination of these methods. Practical experience has shown that, in contrast to other methods, lateral colporrhaphy is less often complicated by a scar process. Ablation or excision of strips of the mucosa from the lateral walls of the vagina enables the diameter of the vagina to be perceptibly narrowed, looseness of the vestibule to be eliminated and the quality of the sex life of the woman and her partner to be improved, but may not be used with prolapse of the pelvic floor. This operation is currently used to treat “vaginal relaxation” syndrome. To achieve a better result, the procedure may be combined with perineoplasty and labiaplasty. We have improved on the classical vaginoplasty method, so we can carry out some of the procedures under local anaesthesia. Thus instead of a scalpel we make use of a latest-generation Surgitron radio-frequency device (Ellman International, USA) which enables us to make incisions with exceptional precision and the minimum of trauma. The procedure takes about 60 minutes, and the rehabilitation period 10-15 days.

Complications following an operation to tighten the vagina include dyspareunia, a defect in the mucosa which takes a long time to heal and stress urinary incontinence. In Goodman and colleagues’ study, 16.6% of women reported complications, including poor healing of wounds, dyspareunia, post-operative haemorrhaging, pain, excessive constriction of the vestibule and injury to the intestine or bladder with the creation of fistulas.

Lasers have been in use for over 20 years for the correction of age-related changes in the vaginal area. Examples include venereal warts and colpectasia and scars from episiotomies and perineotomies. They are also used to treat pre-cancerous diseases of the vulva, kraurosis (sclero-atrophic lichen) and afflictions of the neck of the womb. We and our patients often notice changes to the appearance of the vulva that happen following laser treatment: elimination of hyperpigmentation, and a taut and aesthetically pleasing appearance.

At Professor Yutskovskaia’s Clinic we use laser rejuvenescence of the vagina to treat vulvar kraurosis. The intervention protocol includes treatment with an ablative erbium laser and the use of autoplasma (PRP) and non-stabilised hyaluronic acid.

Use of a fractional erbium laser supports collagen regeneration and enables the skin to be smoothed out and scars to be reduced in size, with no injury to surrounding tissues. Laser vaginal and vulvar rejuvenescence are performed under local anaesthesia. The procedure lasts between 15 and 30 minutes, and the rehabilitation period is five to seven days.

In the past, patients with a high risk of haemorrhage and low regenerative capacity used to undergo vaginoplasty using neodymium, diode or CO2 lasers. Nowadays CO2 and erbium lasers are universally used. The action of the laser is aimed at the submucosal layer, where a thermal impact is used to begin remodelling of the extracellular matrix, which in turn has the effect of increasing the elasticity of the vaginal wall and tightening of the vagina. A. Gaspar and colleagues assessed the impact of two fractional laser systems—CO2 and erbium lasers—in conjunction with the topical use of platelet-enriched plasma and pelvic floor exercises. An improvement in the condition of the vaginal wall and a tightening of the vagina were observed in both groups, but more complications were recorded in the patient group on which a CO2 laser had been used. Complications following the use of a CO2 and an erbium laser include a burning sensation and excessive tightening of the vagina.

Women with vaginal relaxation often complain they no longer feel the same amount of friction during intercourse.  The patient will often describe vaginal looseness and often a decrease in a woman’s ability to attain vaginal orgasms.  The main component of the lack of friction is the relaxation of the inner vagina as well there is usually a component of relaxation at the vaginal opening . A patient has internal vaginal enlargement as well as enlargement of the vaginal opening.

At our clinic we use a sixth-generation erbium laser made by Asclepion (Asclepion Laser Technologies GmbH, Germany). The MCL-31 laser system was first used for a gynaecological operation in December 2013. A provisional analysis of the results of the first 15 procedures supports our view that the level of efficacy and safety of this laser system is high. The rehabilitation period takes three to five days, depending on the individual characteristics of the woman. Protocols are currently being drawn up for procedures with a variety of changes to the vagina.

There are separate reports concerning the use of lipofilling and hyaluronic acid gels with the aim of tightening the vagina. In our view, fillers are not suitable for use in this procedure, and we would like to warn that this procedure is still in the experimental stage.

Despite a lack of studies meeting the requirements of evidence-based medicine, following aesthetic vaginoplasty patient satisfaction is high as regards both medical and functional results and also psychological results. It is not clear whether some kind of ablative or non-ablative laser technology will be developed, or an ultrasound or radio-frequency system, which could be used to address the problems of pelvic floor muscle prolapse. The existence of undesirable events means that lengthy monitoring is needed to analyse long-term efficacy and safety.

Perineoplasty is the surgical procedure that restores a torn perineal muscle, which can make the vaginal opening wider than normal, also known as gaping introitus, epsiotomy damage, perineoplasty damage.

Gaping introitus (enlarged vaginal opening) is usually the result of giving birth, however patients may have enlarged vaginal openings without ever giving birth.  Patients have a separation of the transverse perineal muscles, which causes the base of the vagina to widen.  These are the muscles that are often torn as an extension of an episotomy (a cut made in the perineum made by the obstetrician to widen the vagina to facilitate the delivery of a child) or are torn.  This enlarged vaginal opening can also occur do to a dehiscence or breakdown of a perineoplasty repair performed by a gynecologic surgeon.  This condition gives the patient an “open” feeling and also may cause some lack of friction during intercourse.

Most plastic surgeons who carry out vaginoplasty actually perform a perineoplasty as a simpler method of correcting the anterior part of the vagina. Perineoplasty is often combined with labiaplasty and super-posterior colporrhaphy.

The following indications for a perineoplasty may be listed:

• existence of scarring to the

• looseness of the vaginal vestibule;

• low position of the perineum;

• kraurosis.

The performance method comprises excision of a rhomboid area on the perineum above the anus and within the confines of the vaginal vestibule. The lateral boundaries are the remnants of the hymen. The bulbocavernous and superficial transverse muscle of the perineum are identified, and these are subsequently sutured to create the effect of a tightening of the vaginal vestibule, raising the edges of the vestibule and restoring the structural integrity of the perineum

This procedure is carried out under local anaesthetic with excision of scar tissue using radio-frequency or laser technologies. Use of an erbium laser enables the removal of rough edges and surplus skin, resection of skin neoplasms, enhancement of skin elasticity and elimination of skin hyperpigmentation.

The dimensions of the LMin are individual for each woman and change during the course of her life. In the anterior part, the widest part when spread, the breadth of the LMin is on average from 2 to 4 cm. During the course of life, under the influence of endogenous (hormones) and/or exogenous (injury or wearing of underwear) factors, there is a change in shape and loss of function in the LMin, and such changes are known as involution.

Hypertrophy of the labia minora comes as an increase in the size of the LMin, leading to a decrease in the erectility and sexual hypo-aesthesia both of the LMin themselves and of the tip of the clitoris.

Elongation of the labia minora is a lengthening of the LMin by more than 5 cm in their peak state of extension. Most women think that the ideal length of the LMin should be within 1 cm in a non-extended state.

Protrusion of the labia minora is when the LMin protrude from the sexual cleft, whereas they should be fully concealed by the labia majora (LMaj).

Besides elongation and hypertrophy of the LMin, a distinct, to a greater or lesser extent, asymmetry in them is a common enough observation, linked to anatomical idiosyncrasies and constituting a version of normal development of the external sex organs. Asymmetrical labia usually give women greater discomfort than labia that are evenly enlarged.

Labia minora reduction is the surgical procedure performed to fix the medical diagnosis known as labia minora enlargement (aka labia hypertrohpy)

Labia minora enlargement is one of the most common or the most common cosmetic problems that present to our doctors for potential surgery. Doctors in our clinic never suggest to a patient their condition is a problem, it is only a problem if the patient believes it is problem for them personally. This condition can cause both functional and cosmetic issues.

Patient functional and aesthetic issues include:

• Pain, discomfort, irritation

• Pain during intercourse

• Physical protrusion wearing certain clothing (underwear,
bathing suits)

• Poor genital/body image

Labiaplasty is usually carried out when there is lengthening (elongation) or asymmetry of the LMin. Any non-malignant formations (e.g. papillomas and condylomas) of the LMin may also serve as a reason for surgical intervention. When labiaplasty was being developed, its objective was to reduce the size of the LMin and to remove pigmentation and excess wrinkles, so the main method was considered to be marginal (linear) resection. But this method has serious deficiencies associated with loss of sensitivity and of the natural appearance of the vulva. At many clinics, however, this method is used because it is simple to perform.

Outline resection is carried out according to the canons of plastic surgery, using W-Y- and Z-plasty elements. There is virtually no risk of complications when this is done. When the intervention is carried out, it is best that intradermic sutures are used. One drawback of the method is a lack of efficacy with very distinct pigmentation of the urogenital area.

The de-epithelisation method entails the creation of an elliptical de-epidermised area on the surface of the LMin while maintaining the integrity of the underlying tissues. This is the least destructive method, but still has a number of drawbacks, the most fundamental of which is the lack of potential to use the method with hypertrophy of the LMin to over 4 cm, since in this case their thickness is significantly increased. At the current stage of development of labiaplasty, a combination method is most commonly used, which means outline resection with elements of the de-epithelisation method.

There are dozens of ways and methods of performing this operation, but they all have their own advantages and drawbacks. We have come up with a unique algorithm for selection of a method individually for each patient.

The advantages of the “laser scalpel” over the surgical one come down to a more accurate incision line, absolute sterility and a lack of sutures and scars. The operation time and rehabilitation period are significantly curtailed. LMin correction using a surgical laser is basically carried out using a CO2—and Nd:YAG-laser. We also make use of a radio-frequency method to perform labiaplasty. Following a resection, an intradermic cosmetic suture is usually applied. At the end of the operation, a long-lasting local anaesthetic is introduced into each LMin, which enables the patient to return home with no problem on the day of the operation. Since the area of the genitalia features a good blood supply, the mucosa heals quite quickly and no perceptible scars are left behind.

Following the operation, the recommendation is to apply antiseptic agents to treat the wound margins (five to six times a day) for seven days. For two to three weeks it is best not to go to gyms, swimming-pools or saunas. Sexual contacts are ruled out for up to three weeks. The patient will not have any social life for just one to two days. Complications are encountered extremely rarely when a labiaplasty is performed, and they are mainly linked to individual idiosyncrasies of the body. The commonest complications are haemorrhaging lasting more than three hours and the formation of haematomas, which sort themselves out within no more than four days.

We conducted a retrospective analysis of 130 patient outpatient cards following surgical labiaplasty. Complications were encountered in 12% (15 patients), and these included pain in the area of the post-operative wound that lasted more than three days for 20% (three patients), and LMin hypaesthesia in 46% (seven patients). There was also hyperpigmentation in the post-operative suture zone in 34% of cases (five patients). Through a prospective assessment of the patients’ sexual function before and after the operation, conducted using the Female Sexual Function Index (FSFI) questionnaire, we established that the procedure undergone had had a positive impact on the women’s sexual health.

Plastic surgery on the hood (extreme tip or mantle) of the clitoris. An enlargement of the LMin in the upper third is commonly accompanied by an enlargement of the hood of the clitoris, which leads to an aesthetically unsatisfactory appearance, sexual hypaesthesia and a diminution in sexual satisfaction. Genetics, hormonal changes and the nature of the woman’s sex life may introduce substantial changes into the way the clitoral area looks. A poorly performed labiaplasty, not taking into account surplus skin in the clitoral area, may give rise to a disruption of the structure of this area.

Clitoral hood lift
Patients with elongated clitoral hoods benefit from a clitoral hood lift.

The prepuce or the clitoral hood is located directly over the clitoris and acts as a protective barrier to the clitoris. Excess prepuce is actually excessive clitoral hood and is not a second layer but the same original clitoral hood, which is just excessive. It is not a second structure just an abundance of the same structure and usually helps to completely cover the clitoris. Excess prepuce is not usually removed but only reduced so the patient can have easier access to the clitoral gland for stimulation. The reduction of the excessive prepuce is called “clitoral hood reduction or clitoral hoodectomy.” Most often this procedure is performed for functional reasons.

At our clinic we carry out surgical correction of folds of skin to the side of the clitoris. At the same time as this procedure, correction of the frenulum of the clitoris is carried out to fix the head of the clitoris in a sexually advantageous position. The clitoris and its nerves are not directly involved in this. The procedure of surgical correction of the hood of the clitoris takes place under outpatient conditions, under local anaesthesia. The procedure takes 30 minutes and the rehabilitation period is seven to 10 days.

Correction of the hood and frenulum of the clitoris using hyaluronic acid products. With congenital developmental anomalies or aggressive surgical intervention in the LMin area, it is possible for a situation to arise where the head of the clitoris is not covered by the hood, as it should normally be. This leads to constant difficulty when wearing tight underwear, discomfort and a fall in the number and quality of clitoral orgasms. In this situation the performance of a surgical operation is not possible because of the complexity of the reconstructive techniques and the need for a lengthy rehabilitation period. To correct an existing defect we use high-viscosity gels based on hyaluronic acid which have been specially developed for intimate filling. The procedure takes place under local application anaesthesia and rehabilitation takes three days.

Correction of involution lesions of the labia majora
An enlargement of the LMaj may be associated with loss of elasticity and surplus skin, and also with local fatty deposits. Such an enlargement of the LMaj may, when the woman is wearing trousers, bathing costumes and tight-fitting underwear, look like an unaesthetic convexity, and may also cause discomfort associated with enhanced perspiration in the external sex organs. The LMaj may be enlarged from birth, and they may also change after childbirth or with age. In many women quite large and wrinkled labia are observed following major weight loss, and especially following bariatric surgery. To achieve the optimum aesthetic result, a half-moon-shaped flap of skin is excised on the inside of the labia, and the margins are sutured using a cosmetic suture which is concealed between the labia minora and majora. LMaj plastic surgery is carried out at our clinic under local anaesthesia, and the procedure takes 60 minutes.

Another important problem is deformation of the inferior commissure of the LMaj, which in turn gives rise to looseness of the vaginal vestibule and the entry of intestinal microflora into the vagina—the main cause of recurrent infections of the vagina, urethra and bladder.

Labia majora convergence surgery is performed in women who feel that their labia majora diverge away from the clitoris or away from the perineal body.

When viewing a picture or medical illustrations of patients with this problem, they often complain that their labia majora diverge away and don’t come together. This can occur anteriorly above the clitoral hood and posteriorly below the vaginal opening at the perineum.

Surgery can be performed to pull the majora towards the midline to give a more aesthetically appealing contouring of the majora both above and below the vaginal openings.

Labia majora augmentation surgery is actually performed in a similar manner as the lip augmentation of the face. Injectables are used to puff up the area underneath the stretched skin so the wrinkles will be stretched and thus disappear. The most common injectable is the patients own fat which has been transferred from another area of her body. This is sometimes called an antilogous fat transfer.

To correct the volume of the LMaj, a subcutaneous injection of various fillers is carried out. This is known as intimate filling. Earlier the “gold standard” for LMaj augmentation was lipofilling. This method entails preliminary liposuction and subsequent introduction of aspirated fatty tissue into the area where correction is intended. Purified fat is gathered from areas of local fatty deposits such as the knees, stomach and thighs, and is then treated by passing it through a system of filters. Syringes with a volume of 10-20 ml with a Luer-Lock type lock and blunt-ended 14G cannulas are used for the injections. For stabilisation of it and improvement of its regenerative properties, the collected fat is mixed with autologous platelet-enriched plasma (PRP) at a ratio of 4:1. Experience in the use of lipofilling in other areas of aesthetic medicine has revealed the negative properties of this method, such as low plasticity, lack of predictability of its effect, and frequent instances of the formation of lipogranulomas and filler migration. The mean frequency of complications when this method is used is 6.6%.

In the available literature there is information on the use of liquid silicone, bovine collagen and a polyurethane biopolymer for LMaj augmentation. The authors themselves, however, mention the high risk of complications, associated primarily with the high level of toxicity of the materials and their capacity to migrate and cause aseptic inflammation.

To achieve the desired aesthetic result and to lower the risk of complications developing, a search was made for a bio-compatible filler with optimal physical and chemical properties. A visco-elastic hyaluronic-acid-based gel that is well known to doctors working in aesthetic medicine turned out to be a suitable candidate. There are numerous products now on the cosmetology market which could be used for plastic surgery to shape face and body. As creators of an original method for intimate filling, we recommend the use of the only filler that is currently legitimate—Bellcontour GVISC (HyalIntertrade S.A. Swiss), which we have been actively using since 2005. The lack of immunogenic properties and migration, lengthy biodegradation and unique rheological properties make this the optimal product for intimate filling. All procedures are carried out under local application anaesthesia, and the procedure time is 20 minutes.

At Professor Yutskovskaia’s Clinic we were the first in Russia to make use of the Pelleve radio-frequency apparatus (Ellman International, USA) for intimate plastic surgery. This procedure may primarily be of assistance to patients suffering from unsightly enlarged LMaj which have lost their tone. Patients who previously used to suffer from the so-called “camel toe” (swelling of the LMaj when wearing skintight clothing) may now avoid plastic surgery on the LMaj by undergoing a 30-minute non-invasive procedure.

One question that is under discussion is the use of thread lifting to correct involution lesions to the vulva. We use various Aptos thread systems for this purpose. To correct a loose vestibule and perineum height, the Thread 2G system is used, and the NanoVitis and Excellence Elegance systems (Aptos, Russia) for modelling of the labia minora and majora. Work is currently under way to create a protocol for the performance of this procedure.

G-spot enlargement
The G-spot (lip of the urethra, G point, “12 o’clock zone”, G zone, Gräfenberg spot (zone), internal trigger) is the point of projection of the female prostate onto the anterior wall of the vagina, pressure on which may be a way to achieve erogenous stimulation. G-Shot (enlargement of the G-spot) is a trademark registered in 2001 by David Matlock. This is a low-invasive method of tissue augmentation in the anatomical area to increase sexual excitation during coitus. For quite some time, the legitimacy of this procedure was questioned in scientific reports. When on 18 October 2008 the Federal International Committee on Anatomical Terminology (FICAT), based on studies conducted by M. Zaviacic, included the term “female prostate gland” in its Glossary of Terms, all doubts were resolved.

The G-Shot is a painless office procedure performed in our office under local anesthesia. The actual injection usually takes less than eight seconds and the total time in the examination room is usually less than 10-15 minutes. A specially designed speculum is used to assist in the deliver a specified amount of human engineered collagen directly into the G-Spot after local anesthesia. The G-Shot augments (enlarges) the G-Spot. This results in a G-Spot about the size of a quarter in width, and one fourth of an inch in height (meaning the projection into the vagina). Thus, bringing the woman more in tune with her own sensuality.

The effect can last for up to four months. In a pilot study, 87% of women surveyed after receiving the G-Shot reported enhanced sexual arousal/gratification. Results will vary.

Hyaluronic acid gel is introduced into the submucosal layer in the G-spot area and the gap between the anterior vaginal wall and the urethra, using a drop, linear-retrograde or “fan” technique. The volume of product introduced is 0.5-3.0 ml. A 25-27G needle is used. This leads not only to an enlargement of the G-spot projection zone, but also to a certain diminution in the volume of the vagina, which is particularly marked during sexual contact at the time of formation of what is known as the “orgasmic cuff”. As a result of the intervention, the G-spot projection zone becomes the most protruding part of the anterior vaginal wall, and more accessible to tactile impact, which increases its sensitivity and thus improves the quality of sexual relations.

The introduction of other fillers, such as autologous fatty tissue,  or collagen  may lead to unpredictable results and culminate in complications such as descent of the vaginal wall, stress urinary incontinence, bleeding and infection.

The objective of intimate surgery is to alleviate psychological and/or physical suffering caused by aesthetic or functional deficiencies of the genitalia. Although the number of surgeons engaged in intimate plastic surgery is rising, the increase in patient numbers is being promoted by media activity. Some gynaecologists are unable to comprehend the attitude taken by a woman to her own vulva/vagina. It is becoming clear that modern women have a psycho-biological need to obtain sexual satisfaction as a support for their self-esteem and self-respect. Modern girls and adult women who perform bikini zone epilation have a clear picture of the perineum, its proportions and beauty standards for it. Intimate images that are actively dispersed via the Internet and other media are helping to consolidate an ideal “image” in women’s awareness—a narrow vestibule and delicate labia minora.

Surgeons performing intimate plastic surgery and having a conflict of interests may unintentionally discredit intimate surgery with modern scientific society and potential patients. It is not worth performing procedures on girls who are subsequently planning to become pregnant and who have not yet achieved sexual maturity. Women wishing to have intimate plastic surgery performed should be made aware of all the possible options for correction of the vulva and vagina and examined to see whether they have any pelvic disorders for which proven treatment methods are available. The ethical duties of surgeons in respect of a patient include professional honesty, prevention of any conflict of interests and carrying out the wishes of the patient.

Dr Evgenii Leshunov is a Urogynecologist, genital surgeon, “Clinic professor Yutskovskaya” Moscow, Department of Urology GBOU DPO RMAPO. He is also Scientific coordinator of the International Association of Gender Medicine. The methods of performance of the procedures are described in this article considering the reports of surgeries made in the clinic of Prof Yutskovskaia.

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